“I read your blog often, and would like to pick your brain on a question if you have a moment. I'm a mom and a big believer in women's right to choose where, how, and with whom to birth. I am also an aspiring midwife, and I feel stuck between a rock and a hard place, so to speak, in choosing the right path for me. So I'm writing for some advice. Are there any direct-entry programs in the US that you feel provide adequate and appropriate training for midwives? I have considered doing the CNM route, but I do have doubts about my ability to work in a hospital as a nurse, and about that kind of training as well. Will it be as holistic as I hope? The CNMs I've met tend to be more obstetrically-minded than I'd hoped (though maybe this limited experience has biased me unfairly).

Anyway- I want to be as well prepared as possible. I realize there is real risk inherent in birth and I know I won't be comfortable with myself as a care provider unless I feel I've sought the best training possible. I'm sure a lot of this is in the apprenticeship/clinical portion, but I know the formal ‘schooling’ is really important too. Any advice you might give would be much appreciated. Like I said, I read your stuff often, and appreciate your skepticism.”

I share this email because I’m being asked this more and more. And while I’ve addressed it a couple of times, it seems the cycle has come around again to talk about it.

First, the only complete education and skills training program I think is more than adequate is Florida’s process to becoming a midwife. The Florida School of Traditional Midwifery (which happens to be MEAC-accredited as well) is the school I’m most familiar with. If there had to be a litmus test of other schools, it would be that they are MEAC-accredited and cost a buttload of money. $20,000+ gets you a pretty decent education. Beware the discounted and we’ll-get-you-through-fast programs. The road to becoming a midwife should be long and arduous. And expensive. There’s a reason for that. It is only through time does a woman witness a great variety of births and birth scenarios. Hypothetically, a midwifery student could attend 40 homebirths and never see anything more dramatic that sticky shoulders or a woman needing pit to stem a mild hemorrhage. It isn’t until the real difficulties occur –and many of those are so subtle as to be easily missed by the novice- that a midwife learns her skills.

Women wanting to be midwives (and I know there’ve been a few men interested, but in general it’s women) seem to want to zippity-doo-dah through the process. I know I sure did. I thought I’d seen enough already, that I knew so much, it was a mere technicality towards my having a license. How wrong I was. So much more responsibility is necessary than even I thought (and I’d already been to about 700 births by the time I got my CPM). There’s a world of difference watching/assisting and being responsible for the two lives. Only experience can develop that reality. And not being the Primary midwife, but a Primary Under Supervision of a very experienced midwife. It disturbs me, midwives who’ve had less than ten years of experience teaching apprentices. How can they teach when it isn’t even ingrained in them yet? (And I had an apprentice when I first got licensed. One of the stupidest things I ever did was believe I could teach someone the gamut of midwifery skills when my own weren’t even honed.)

So the reader’s questions aren’t black & white answers.

If you are more holistically-minded and think you will be brainwashed in Nursing School, perhaps you aren’t so strong in your beliefs or Nursing School has a lot of reality to teach.

If you find a great school to attend… MEAC-accredited, expensive and extensive… you will still need to find an experienced midwife to apprentice with. And your apprenticeship needs to be years long in order to get the proper and adequate education.

If this sounds daunting, good! It should be.

Now, looking at becoming a CNM, all schools to become a nurse and then midwife share the same quality education. You can pick a school anywhere in the country and know you’ve chosen well. Then, when you are doing your skills training, you know that almost all teachers have a certain level of knowledge and training themselves. If you happen to get a crappy mentor, wait a few weeks and you’ll get a different one. You learn from many different mentors, not just the one or two you apprentice with as a home birth student midwife.

Each non-CNM midwife has what I call “black holes” in their education and skills training. When they teach, they also teach the black hole… or rather, they leave out the knowledge of the black hole, thereby passing on the black hole from generation to generation of apprentices/midwives. Unless a student/apprentice has another midwife that accidently fills in the black hole, she can go her entire life not knowing about something. For example, I just reported on a study that showed “Heat Wave May Make Womb a Dangerous Place,” that heat was positively associated with congenital cataracts. When I reported on it, I noted that I’d not known babies could have congenital cataracts. Another midwife was surprised (understatement) that I didn’t test for them, looking in the newborn’s eyes with a flashlight to look for the “red reflex” (you can bet I know about it now!). I’ve had at least ten midwives teaching me how to do newborn exams and I can’t remember even one of them telling me about the red reflex. Clearly, this was a black hole in my education… and one I passed on to my apprentice as well. Hopefully, she’s learned about it since then. As an aside, I’m reading the new edition of “Heart & Hands: A Midwife’s Guide to Pregnancy and Birth” to review it here on the blog. H&Hs was a staple in my midwifery education, we nearly memorizing it for our NARM exam. I’m assuming Anne Frye’s replaced H&Hs, but know this is still an extremely important text for student midwives. In here it says:

“Check the eyes for red spots, hemorrhages of the sclera due to pressure in the birth canal. Also look for evidence of jaundice: (sic) the whites of the eyes should be white, not yellow. Check to see if the pupils are equal in size and reactivity when exposed to light. Check for tracking by moving your finger back and forth close to the baby’s face. Check the shape and spacing of the eyes, noting any irregularities.”

Then it goes on to erythromycin in the eyes, but nothing about red reflexes. It bothers me that it isn’t in there and disturbs me that I never checked a baby’s eyes for cataracts. I can only pray none of them had one or the Pediatrician found it if there was. That was a roundabout way to explain a black hole, but there you have it. It is unlikely this would happen in nursing and midwifery school.

I believe CNMs tend to be more medically-minded because they see far more than a home birth midwife does and understand the necessity of being on your toes in birth. One of my favorite midwives, who was also one of the most laid back, had an amazing education at Grady Memorial in the heart of Atlanta, attending to HIV patients and a wide variety of not-really low-risk clients, but learning what was normal and what, most definitely, was not normal. She was one of the best midwives I’ve ever worked with, gentle with clients while making sure they were safe and healthy. And then there’s the “hands-off” midwife I once was who didn’t listen to fetal heart tones because a mom didn’t want me to. You tell me who was acting correctly in birth. Just because I was filled with woo didn’t mean I was doing the right thing. There is balance and balance can only be found with education and training.

You have to know it all (or as much as possible) in order to make informed choices. That goes for midwives as much as it does our clients. If we aren’t aware of all our choices, how do we offer our clients the best care out there? We can’t.

It’s true. I am all gung-ho for CNMs now. Actually, it’s for their education. It’s just the more I know and the more I hear, the less I like the CPM education. It scares me in many ways. Most of what scares me is the arrogance of the groups behind the education process. Instead of seeing the gaping holes and trying to fill them, they pretend to fill the hole with a teaspoon of dirt. Why can’t NARM see that Biology, Anatomy & Physiology and other science classes should be required for the CPM license? Why, when they had the chance to add classes, they chose a class in cultural sensitivity? (Not that that isn’t important, but so are basic classes like the ones mentioned above.)

Dear reader, if you’re looking for the most comprehensive education process, there is no question. You will learn more, see more and do more in any CNM track than you would if you were going through the CPM path. While the argument is often said that CPMs learn normal birth whereas CNMs learn more complicated, medicalized birth, I’ll say that when the shit hits the fan in birth… and it does… knowing normal birth doesn’t save the lives; knowing complicated means does.

I look forward to your thoughts about what I’ve said. As well as others, too.

Reader Comments (17)

What wonderful timing this post has for me. I have been discussing this topic with my family for the last few days after having a rather bothersome conversation with a CPM about how "limiting" it is to become a CNM. I feel you continue to help keep me on true North towards nurse midwifery. I am so grateful to you for your continued encouragement; maybe you aren't speaking directly to me, but it is definitely moving directly through me. Since this road is long, and fraught with sacrifice, you continue to reassure me I have made the right choice, which I sorely need from time to time. So here is to you Barbara, because I am here largely due to your sharp logic and encouragement for women who want to be midwives to consider nurse midwifery. I start nursing school in 7 weeks.

I have never understood the "I don't want to go the CNM route (or the med-school route) because I might get brainwashed" rationale. If you get the education, you're in a position to determine which (if any) portion of it is not useful. If you don't, you're simply acting from a position of willful ignorance.

I would also argue that any midwife who wants to practice out-of-hospital has an even greater responsibility to get the most extensive education and broadest experience possible before she begins practice. In hospital, there is always the chance that someone else will be available to help you (and your client) out in the event of an unforseen complication. At home, it's all you, baby. And that's why the "expert in normal birth" and "specially trained for homebirth" tropes are harmful baloney. You need to be an expert in abnormal (as in spotting it early) and "specially trained" to intervene with little support.

Many, many years ago, when I became a certified Lamaze instructor, I was surprised to discover that all my classmates had no other credentials than that they themselves had used the Lamaze method during labor successfully, and had the convert's zealousness about its efficacy. I think a great many women who want to become midwives are the same: they have given birth, often having had uncomplicated and fairly brief labors, and they think everyone is like they are.

But that's wrong. As you point out, for one thing, a midwife's education is ongoing. Secondly, while there is no real problem with being taught a methodology that one perceives as "medicalized" and then, FROM A POSITION OF KNOWLEDGE, making adjustments in one's personal practice, there is a very real, and dangerous, problem with beginning from a position of ignorance. As you state, two lives are at risk. EVERY birth has the potential to become complicated, even if the statistics show that most don't.

CNM is the ONLY way to go. And I happen to think that this ought to be made a legal requirement, on a Federal level, so all states adhere to a single standard. That way, a woman seeking a midwife can have some degree of assurance that the midwife she hires is qualified and competent. Further, I think that all CPMs should be assisted to become CNMs in some sort of special upgrade track that gives them credit for experience.

I don't really understand this "if I study in a hospital I will become too medicalized". Phooey. What a person is saying when she says that is "I'm afraid of being convinced there is a better way". If she wants to be a really good midwife, and not just a birth junkie, why should she fear expanding her knowledge? It's not as if someone is going to stand over her with a club and tell her she MUST practice in a certain fashion or else!

Great post as usual! I have many of the same thoughts, the more I learn about CPM training. That's not to say that all CNM programs would be fan-tabulous-astic...there are mediocre programs in every profession and I have heard people complaining about the level of instruction and clinical experience in their CNM programs. But it seems like the "basement" for CNM programs is higher than that of CPM programs.

I do have some understanding for the concern that hospital training will not be holistic...too medical, as you are concerned the CPM training is not medical enough. Those "black holes" exist in the medicalized setting, they're just for different things (like patience!!) That's not to say there's something wrong with pursuing CNM training in general, but that it's not an unfounded fear that it might be hard to find clinical experiences that will teach you all the pieces of being a midwife...the normal as well as the higher-risk.

Just because you go the CNM route does not mean that you will have to work as a nurse for an extended number of years before continuing on to become a midwife. There are many "direct entry" aka "graduate entry" programs in the country that are made for those with a bachelor's degree in another field. I do not know if this is the case with the reader who wrote the question. But, the way the work is that in order to apply, you are required to take certain pre-requisite courses (A&P, developmental psych, stats, etc.). You are then admitted to a certain specialty, being nurse-midwifery in this case. The first year to year and a half of the program is spent taking general nursing courses. After that time period, you sit for the NCLEX (boards to be an RN), and upon passing that, you continue on to the graduate portion of the program (with the rest of the grad students -- those who have worked as nurses) to study midwifery. Then you will graduate with your MSN and sit for the boards to be a nurse-midwife.

Just another option to keep in mind for those that already have a degree and may not want to go the whole BSN route before going for the MSN.

This website lists all those programs: http://midwife.org/rp/eduprog_options.cfm?id=2

Navelgazing Midwife, what do you think of the CM certification vs. CPM and CNM? I currently live in a state that recognizes only CNMs. I've always been a proponent of homebirth, but lately I've been rethinking my support for the CPM certification. I'm not sure where to go from here, though. What do I tell people I am in favor of? We have a LOT of underground homebirthing going on here and it scares the crap out of me - the CPM seems a much higher standard than what we are currently seeing in our area, which is no training and a whole lotta woo. There are only maybe 2 homebirth CNMs in the whole state so women feel a real pinch when it comes to options.

Not NGM, but here's my take on the various "alphabet soup" of so-called midwifery credentials other than CNM [LM, CM, CPM]: they are at the best completely inadequate, at worst, simply certifying almost criminal ignorance. The titles are designed to trick unsuspecting women into thinking that the holder of the qualification is on a par with a CNM. A lot of women hear the "professional" in CPM and think they are in good hands, and the same holds true for CM [certified where and in what?] and LM [having a "license" sounds as if there is supervision]

I know that sounds harsh, but lives are at risk here. Would you go to a dentist whose only education was that of a veterinarian? After all, dogs have teeth, too!

A CM in the way the commenter meant was the ACNM Certified Midwife, NOT the state-licensed Certified Midwife. That the ACNM decided to use the title CM is one of the most confounding things out there. An ACNM CM is *not* a rogue, CPM-type midwife, she is a direct-entry CNM, removing the N because she's not a nurse.

There is a HUGE difference between ACNM-CMs and the state-given designation of CM.

I do not believe that ANY form of direct entry midwifery can be as comprehensive as midwifery as a post graduate course following nursing studies.

While most pregnant women are well, a substantial number are either not, or have significant medical histories which are pertinent to pregnancy, labor, and/or birth. The woman herself may be unaware that this is so, btw. CNMs care for ALL pregnant women; sometimes under medical supervision, sometimes autonomously.

It is vastly important that there be one standard, and only one standard for midwives. Otherwise it's just chaos, and dangerous chaos, at that.

I simply don't agree! This kind of rhetoric continues to fuel a battle of "who's the best" between midwives trained traditionally and midwives trained medically. I feel it continues to support the medical model and hospitalized birth over homebirth. It also perpetuates the myth that direct entry midwifery training is sub-par to nurse-midwifery training. They are different types of training for different kinds of midwives. I think the type of training needed should be determined by the birth setting.

In my personal experience a direct entry midwife is far better equipped to deal with emergencies in the field than a nurse-midwife. Nurse-midwives on the other hand are more equipped to deal with emergencies using hospital medical interventions. Both are valuable, but different.

I think there is certainly room for both kinds of midwives! Saying one is automatically a safer choice---is in my opinion---NOT TRUE!

Amy Grace -- "In my personal experience a direct entry midwife is far better equipped to deal with emergencies in the field than a nurse-midwife."

What is your experience?

I don't know why you feel that a CNM necessarily treats a patient "medically", btw, when there is no need for it. The best way to use technology is to use it SENSIBLY. Neither maxi-use nor mini-use should be the overriding principle: the way a patient is treated should be the appropriate way for that patient. By deliberately choosing not to become a nurse, however, you are inevitably denying your patient anything but the minimal use of technology, no matter what the situation, which can possibly endanger both the woman and her baby.

Antigonos, I find it odd that you attack the post-graduate educational program designed by ACNM to create the credential of Certified Midwife. CMs, while not recognized in all states, do get the same level of of education and experience as CNMs, take the exact same boards to become certified, and also work in hospitals and have the same scope of care as CNMs. To make up for the lack of nursing education, CMs do take many prerequisites and extra coursework. My understanding is that politics have prevented the CM from becoming a national credential. It is mostly designed for the midwifery candidate who already has a Bachelor's degree but is not an RN or BSN. If your concern is education and experience, why eschew midwives who meet the same standards as CNMs?

From Atigonos: "Further, I think that all CPMs should be assisted to become CNMs in some sort of special upgrade track that gives them credit for experience."

I would love to see this happen. I haven't ruled out becoming a CNM or even going to medical school after getting my CPM, but the "starting over" element of not receiving any credit for the 3+ years of supervised clinical and didactic education I have worked hard to obtain is definitely a frustration.

I'm all for improved educational standards with the CPM credential and more integration to make continuing education to become a CNM a realistic and accessible option.